Ohio Health Insurance Options

Transcription

1 Application Instructions For Medical Mutual of Ohio 1. Print all pages of the application including instructions. 2. Complete all questions and sections of the application. 3. Complete the fax cover letter on the next page and fax to Ohio Health Insurance Options for review along with the completed application. If you do not have access to a fax machine, send the completed application to along with the required first month's payment. HELPFUL TIPS: Here is a checklist of a few things that are commonly overlooked and are mandatory in processing your application. Indicate your requested effective date. Select your preferred billing method. Sign and date the application. IMPORTANT: If you have requested that your monthly premium be deducted automatically from your checking account, you must attach a voided check to the area provided and also sign and date the authorization form. Don't forget to enclose a check for the required payment made payable to Medical Mutual of Ohio if you are not paying by credit card for the first month. Mail completed application and check to: Attn: New Enrollment PO Box 1481 Reynoldsburg, OH will review your application for completeness and accuracy before we submit it to Medical Mutual of Ohio for processing. This may reduce the approval time because they cannot process unclear or incomplete applications until the missing information has been gathered. Please contact us if you have any questions regarding the application or the application process. You may reach us at or us at ohioinsoptions@aol.com.

2 FAX COVER LETTER (Please ignore this form if you do not have access to a fax machine.) **Please FAX this cover letter with the completed application to: FAX# Dear, Please accept my completed insurance application for submittal and contact me to confirm receipt of this application Name Date Time Please contact me at this phone number after you have reviewed my application for completeness and accuracy. I will contact at to verify receipt of my application. **I understand that will not review this application until the following business day if I faxed this application after 5:00PM or on a weekend I understand that the original signed application must still be mailed to. I will mail the original signed application to : Attn: New Enrollment PO Box 1481 Reynoldsburg, OH I will send the original application as soon as I have been contacted by with confirmation that my application has been received by fax and reviewed for completeness.

3 MMO USE ONLY EFFECTIVE DATE: / / GROUP NO.: HEALTH & LIFE APPLICATION/CHANGE FORM OHIO INSTRUCTIONS: All questions must be answered. Incomplete applications will be returned. SECTION I: CONTRACT HOLDER INFORMATION Last Name MI First Name SS Number Marital Status: Marriage Date Divorce Date Single Married Divorced Separated Widowed Permanent Residence Address City County State Zip Code Area Code and Phone Number Occupation Reason for Application: Applying for New Coverage Applying for Dependent Only Coverage Applying for a Change to Current Coverage LIST BELOW ALL INDIVIDUALS TO BE COVERED Self Spouse First Name, MI (and Last Name if different) SS Number bacco Birth Date Sex Height Weight User Physician Student / / Y N / / Y N / / / / Y N / / Y N Y N Y N Y Y N N SECTION II: FEDERAL AND OHIO OPEN ENROLLMENT ELIGIBILITY 1. Yes No Are you a Federally Eligible Individual or applying for coverage under the Ohio Open Enrollment requirements? If Yes, STOP HERE. SuperMed One is NOT a Federally Eligible or Ohio Open Enrollment product. For an information and application packet, please call Medical Mutual at Please note: SuperMed One may affect your status as a federally eligible individual. Visit for A Consumer s Guide to Getting and Keeping Health Insurance. SECTION III: PRODUCT HEALTH INSURANCE (Preferred Provider Organization Uses SuperMed Plus network): Note: Health Insurance products are medically underwritten. Desired effective date (when coverage is to begin): / / $500/$1,000 Deductible $1,000/$2,000 Deductible $1,500/$3,000 Deductible $2,500/$5,000 Deductible $5,000/$10,000 Deductible Short-Term $500/$1,000 Deductible Value Plan - $500/$1,000 Deductible Value Plan - $1,000/$2,000 Deductible Value Plan - $1,500/$3,000 Deductible OPTIONAL RIDERS: (Can only be purchased along with health insurance) $15/$30/$45 Prescription Drug Copay Maternity Services OPTIONAL COVERAGE: Dental 1 Vision 1 SaveWell 1 Critical Illness Benefit 2 Applicant: $5,000 $15,000 $25,000 Spouse: $5,000 $15,000 $25,000 Life 2 (If selected, complete beneficiary designation section on next page) Applicant: $15,000 $25,000 $50,000 Spouse: $15,000 $25,000 $50,000 1 Can be purchased as a stand alone product. If purchased as stand alone product, one year of premium is due with payment of first bill. 2 The critical illness and life insurance is underwritten by Fort Dearborn Life Insurance Company. This product offering is only available if you are approved for Medical Mutual of Ohio permanent health insurance. It is not available with the short-term health product. X5119 R12/05

4 SECTION III: PRODUCT (continued) Will this Life Insurance replace any existing insurance with this or any other company? Applicant: Yes No Spouse: Yes No Name of Company APPLICANT S BENEFICIARY DESIGNATION SPOUSE S BENEFICIARY DESIGNATION PRIMARY CONTINGENT PRIMARY CONTINGENT First Name Last Name Date of Birth Relationship / / / / / / / / S.S. Number SECTION IV: OTHER COVERAGE INFORMATION 1. Yes No Do YOU, your SPOUSE or any listed DEPENDENT have any other type of (Accident, Medicare, Medicaid, etc.) or are you currently applying for any other health insurance? If yes, please complete the following: NAME TYPE NAME OF INSURANCE COMPANY 2. Yes No Were YOU, your SPOUSE or any listed DEPENDENT covered by another health plan within the last 63 days? If yes, please complete the following: NAME NAME OF INSURANCE COMPANY DATE OF COVERAGE

5 SECTION V: MEDICAL ELIGIBILITY A. Yes No Are YOU, your SPOUSE or any listed DEPENDENT currently pregnant or an expectant parent? Name Due Date B. Yes No Are YOU, your SPOUSE or any listed DEPENDENT currently taking any prescription medications? NAME MEDICATION AND DOSAGE MEDICAL CONDITION C. Yes No Has any insurance company refused, restricted or charged more for health coverage on any person listed on this Application? NAME REFUSAL OR RESTRICTION MEDICAL CONDITION D. Yes No Do YOU, your SPOUSE or any listed DEPENDENT has a condition covered by Workers Compensation? NAME WORKERS COMPENSATION NUMBER MEDICAL CONDITION E. Yes No In the past five years, have YOU, your SPOUSE, or any listed DEPENDENT engaged in sports or hobbies such as scuba diving, automobile or motorcycle racing, skydiving or aero sports on a regular/routine basis? If YES, please complete the following: NAME SPECIFIC ACTIVITY F. When was the last time YOU, your SPOUSE, or any listed DEPENDENT saw a physician? Please complete the following: NAME DATE REASON RESULTS

6 SECTION VI: MEDICAL ELIGIBILITY (Continued) G. Have YOU, your SPOUSE, or any listed DEPENDENT within the past ten years been treated for, diagnosed as having, hospitalized, had surgery, been recommended for future surgery, diagnostic testing or medical treatment or thought you should seek medical advise for any of the following conditions? Each condition must be checked ( ) Yes or No CONDITION YES NO CONDITION YES NO CONDITION YES NO 1. Abnormal Pap Smears 2. AIDS, ARC, or HIV 3. Allergies 4. Alzheimer's Disease 5. Aneurysm 6. Anorexia/Bulimia 7. Arthritis (Type: ) 8. Asthma 9. Back Sprains/Strains 10. Bronchitis 11. Bursitis 12. Cancer (Type: ) 13. Cardiomyopathy 14. Carotid Artery Disease 15. Carpel Tunnel Syndrome 16. Cataracts 17. Cerebral Palsy 18. Cholesterol (High) 19. COPD or Emphysema 20. Cirrhosis of the Liver 21. Colitis (Including Ulcerative) 22. Colon Polyps 23. Congenital Disorders 24. Congestive Heart Failure 25. Coronary Artery Disease (Including Angina and Angioplasty) 26. Coronary Insufficiency 27. Crohns Disease 28. Cystic Fibrosis 29. Cystitis (Chronic or interstitial) 30. Cysts, Tumors or Growths 31. Diabetes/Blood Sugar Disorder Last 3 Blood Sugars & Dates: 1) 2) 3) 32. Diverticulitis/Diverticulosis 33. Down s Syndrome 34. Drug/Alcohol Abuse (Including DUIs) 35. Endometriosis 36. Fibrocystic Breast Disease 37. Fibromyalgia 38. Gallbladder Disease 39. Gastric Reflux (GERD) 40. Gout 41. Graves Disease 42. Growth Deficiency 43. Guillian Barr Syndrome 44. Heart Attack 45. Heart Bypass Grafting 46. Heart Murmur 47. Heart Palpitations/Arrhythmia 48. Heart Valve Disorders 49. Hemorrhoids 50. Hemophilia 51. Hydrocephalus/Shunt 52. Hypertension (High Blood Pressure) Last 3 Pressures & Dates: 1) 2) 3) 53. Ileostomy/Colostomy 54. Infertility 55. Kidney Failure 56. Kidney Stones 57. Liver Disorders/Hepatitis 58. Lou Gehrig s Disease (ALS) 59. Meningitis 60. Menstrual Disorders (including Abnormal Cycles/Uterine Bleeding) 61. Mental Health Disorders (Including Depression, Anxiety, ADD/ADHD and counseling) 62. Migraines 63. Multiple Sclerosis 64. Muscular Dystrophy 65. Organ Transplant/Failure 66. Osteoporosis 67. Otitis Media (ear infections) 68. Ovarian Cyst/Polycystic Ovarian Disease 69. Pacemaker Implantation 70. Pancreatitis 71. Paralysis 72. Parkinson s Disease 73. Peptic/Gastric Ulcer 74. Peripheral Vascular Disease 75. Phlebitis/Blood Clot 76. Polycystic Kidney Disease 77. Prostate Disorders 78. Schizophrenia/Bipolar 79. Scleroderma 80. Seizure Disorder/Epilepsy 81. Sexually Transmitted Disease 82. Sleep Apnea 83. Spina Bifida Cystica/Occulta 84. Spinal Disorders/Disc Disease 85. Stroke 86. Suicide Attempts/Psych Admits 87. Systemic Lupus 88. Tendonitis 89. Thyroid Disorder 90. TMJ 91. nsillitis 92. Transient Ischemic Attacks (TIA) 93. Varicose Veins 94. Other condition(s) not listed H. If any questions A through F or conditions 1 through 94 are checked YES, please explain below, (use additional paper, if necessary). Indicate all details of the injury, ailment or condition. Include items such as specific location of condition (example: right knee), diagnosis, type of treatment and hospitalization. Question/ Condition Start and End Patient's Name Details of Injury, Ailment or Condition Date(s) of Physician Treatment(s)

7 SECTION VII: BILLING INFORMATION CHOOSE ONE: HOME Receive monthly premium billings FINANCIAL INSTITUTION Have monthly automatic premium withdrawals If you wish to be billed through your financial institution, please complete the following authorization: I authorize Medical Mutual of Ohio to initiate premium deductions from my account. The authorization will remain in effect until Medical Mutual of Ohio and my financial institution have received written notification from me within a reasonable time period to allow termination of the deduction. Premiums are to be deducted from: Checking Savings (Please note: Not all Financial Institutions allow deductions from a savings account. Please verify this information with your financial institution.) Name and branch of bank/financial institution (Must be in Ohio) Address Account Number Account Holder s Name City State Zip Code Transit Routing Number: Account Holder s Signature Date Please attach a voided check for checking account or a deposit slip for savings account in order for our office to verify the bank information. CREDIT CARD Have monthly premium billed to credit card If you wish to be billed through your credit card, please complete the following authorization: MasterCard Visa Card Holder Name Bank Name (If applicable) Account Holder s Signature Card Number Expiration Date Date LIST BILLING THROUGH EMPLOYER is available only to employees of a common employer who has agreed to collect the premiums on a monthly basis through payroll deduction and where the employer is not paying any portion of the premium. Name of Employer Occupation Address Area Code and Phone Number City State Zip Code DIFFERENT BILLING ADDRESS Have home billing sent to a different address If your mailing address is different than your permanent address, complete the following: Last Name (C/O) First Name MI Address City State Zip Code ATTACH VOIDED CHECK OR DEPOSIT SLIP HERE FOR OFFICE USE ONLY Sold - Account Executive and Code Service - Account Executive and Code or Agent of Record Mark A. Dunn Royal Advantage Broker Tax ID 1896 Commission Indicator 96.15

8 SECTION VIII: TERMS AND CONDITIONS I hereby apply under Medical Mutual of Ohio s Group Trust and/or Fort Dearborn Life Insurance Company for the coverage indicated on this application. I further agree to participate in such trust and agree to be bound to the relevant terms of the Master Group Contract(s) and the Trust Agreement. 1. I authorize release of information, without limitation, from any medical/medically related facility, prior health insurance carrier, government agency or person to Medical Mutual of Ohio (MMO), Fort Dearborn Life Insurance Company (FDL) and/or any affiliates or division of MMO or FDL: (a) to evaluate this application; (b) to adjudicate claims submitted on behalf of me or my dependents; (c) for utilization review programs to monitor health services or quality improvement activities; (d) for credentialing purposes. I authorize the applicable carrier to provide a photocopy of this release to any physician or medical institution to obtain records for the purposes stated above. This authorization will be valid for a period of two and one-half years for the purpose of collecting information regarding this application. 2. I agree that a medical examination of me may be required in connection with this Health and Life Insurance Application. I further agree that I, as the Applicant, will be responsible to pay for the medical examination and/or the release of any and all records on behalf of myself, my spouse, and/or the listed dependents. 3. I represent that I have read this Health and Life Insurance Application, and understand each of the questions and the answers to each of the questions I have given are complete and true to the best of my knowledge. I agree that any intentional misrepresentation or concealment on this Application will void my policy at the discretion of MMO and/or FDL. I further agree that if a policy is issued, it will be issued by MMO and/or FDL (if applicable) in full reliance and in consideration of the information, answers, and statements contained herein. I understand that this policy will be medically underwritten. 4. I have read the sales materials and understand the plan benefits, exclusions, and limitations as outlined therein. I acknowledge that the managed care features of this coverage (such as the preferred provider organization network) have been explained to my satisfaction. I also understand that I may review a copy of the Master Group Contract(s) and Trust Agreement upon making such a written request to MMO or FDL. 5. No issuance, waiver, modification or change of contract or any of MMO and/or FDL s rules or amendments shall be binding upon MMO and/or FDL unless it is in writing and signed by an authorized officer of MMO or FDL, as applicable. 6. Notice: Certain Pre-Existing Condition limitations will apply. 7. I represent that neither I nor my spouse are receiving any form of reimbursement or compensation for this coverage from any employer. 8. I also understand that information submitted with this application may require further medical underwriting. If that underwriting discloses additional medical risk I understand that there may be a significant change in the rate charged for this coverage or in certain cases, the coverage may be rescinded. A permanent ID card will be issued following the final review and acceptance of the application. 9. I understand and agree that life and/or critical illness insurance will not become effective until FDL has accepted and approved my application and I have been notified by FDL. Any premium payment will be deposited immediately upon MMO s receipt of this application. Should FDL not approve my application, my payment will be refunded in full. 10. I understand and agree that I am solely and exclusively responsible for all of the answers contained in this application. I understand and agree that no agent or broker who may be assisting in the completion of this application has any authority (a) to waive any answer or any portion of any answer to any question on thos application or any information MMO requests, (b) to advise me that I am not obligated to disclose any condition of which I am aware concerning my health or the health of any dependent included on the application, (c) to make any representation concerning health benefits that are inconsistent with, or different from, any written information provided by MMO and/or FDL or (d) to bind MMO or FDL in any way by making any statement, promise or representation that is not set out in writing in this application or regarding eligibility, benefits or issuance of a policy or (e) to approve coverage. 11. I understand and agree that I am responsible for disclosing all information required by this application, including but not limited to all health conditions and diagnoses of which I am aware. I understand and agree that MMO and/or FDL has the exclusive right to determine whether a particular condition or diagnosis is significant, that I do not have the right to evaluate whether a condition or diagnosis should or should not be disclosed on this application and I am obligated to disclose even those conditions or diagnoses that I do not believe are significant or important. I am signing this Health and Life Application on my own behalf and on behalf of all listed dependents. An unaltered copy of this authorization is as valid as the original. Do not cancel any current health insurance coverage until you receive an approval letter and insurance policy from Medical Mutual. Contract Holder s or Guardian s Signature Date Guardian s Social Security Number if child only policy Spouse s Signature Date Dependent s Signature if 18 or older Date Dependent s Signature if 18 or older Date Dependent s Signature if 18 or older Date SECTION IX: HOW DID YOU HEAR ABOUT PERSONAL HEALTH PLANS (CHECK ONE)? 1. Friend / Family Member 2. Yellow Pages 3. Insurance Agent 4. Advertisement in Newspaper, Magazine, etc. 5. Newspaper Article 6. Internet / Web site 7. Radio 8. Mail 9. Through current employer 10. Other WARNING: Any person who, with intent to defraud or knowing that he is facilitating fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. (Ohio Revised Code Section )